Introduction

Over the years there has been an evolution ofliterature supporting the use of non invasiverespiratory support (NRS) to manage a widerange of respiratory pathologies. Cliniciansare working to develop protocols and guide-lines to prevent ventilator associated pneu-monia (1). The use of NRS may have a rolein even the most complex patients. We wishto describe the management of a multi-trau-ma patient and how he benefited from a noninvasive ventilation protocol.

Case report

PF was a 42 year-old male restrained driver ina two car motor vehicle accident who wasbrought by ambulance to the trauma bay. Thepatient was intubated by the emergency de-partment physicians for airway protectionand underwent diagnostic imaging. His in-juries on exam included: Ascending aortictransection, left sided thalamic and frontallobe hemorrhages with diffuse axonal injury,bilateral pneumothoraces, left hemothorax,left diaphragmatic rupture, C7 transverse

51Non invasive respiratory support in a multi-trauma setting

Applied Cardiopulmonary Pathophysiology 15: 51-54, 2011

Non invasive respiratory support in a multi-trauma setting: A case reportI. Condon1, P. Papadakos1,2

1Department of Anesthesiology University of Rochester, USA; 2Departments of Surgery

and Neurosurgery University of Rochester, USA

Abstract

Introduction: Non invasive respiratory support has been used in a wide variety of settings.This case report illustrates the benefit of such support in a complex multi-trauma patient. Case presentation: A 42 year-old male restrained driver was brought to the trauma bay withmultiple injuries. These included: aortic transection, frontal lobe hemorrhages, bilateral pneu-mothoraces, multiple rib fractures, diaphragmatic rupture, C7 fracture, and pubic rami frac-tures. After surgical repair, the patient was transferred to the Kessler Burn Trauma ICU sedat-ed and ventilated. Serial bronchoscopies were performed to improve aeration of his left lungover the next week. The patient was extubated on POD # 9 but required reintubation the fol-lowing day due to lung collapse. A regimen of non invasive positive pressure ventilation wasinitiated to avoid reintubation for repeated bronchoscopies. The therapy was successful andthe patient progressed to room air after one week.Conclusion: Studies have strongly supported the use non invasive respiratory support for re-ducing morbidity and mortality of specific groups of patients in acute respiratory failure. In thiscase report it was used successfully in an acute multi-trauma patient. Non invasive respiratorysupport should be considered for the prevention and treatment of acute respiratory failure ineven the most complex patients.

Key words: multi-trauma, non invasive respiratory support, atelectasis, diaphragmatic dysfunc-tion

process fracture, right 1-3 rib fractures, left 1-10 rib fractures and subsequent flail chest,and bilateral pubic rami/acetabular fractures.He was taken to the OR emergently and un-derwent total endovascular aortic repair witha carotid-carotid bypass, and exploratory la-parotomy for spleenectomy and repair of hisdiaphragmatic laceration. Bilateral chesttubes were placed. Post-operatively, the pa-tient was taken to the ICU and placed on air-way pressure release ventilation (APRV) andlater, changed to pressure regulated volumecontrol (PRVC) ventilation. Neurosurgeryplaced and ICP monitor at the bedside.

Three days post-operatively, PF was noted tohave worsening aeration of his left lung.Fiberoptic bronchoscopy was performedand large amounts of thick, bloody mucouswas removed and some improvement in hischest x-ray was noted. On POD #5, portablechest x-ray showed a near total opacity of hisleft lung (figure 1). Again, a bronchoscopywas performed and thick, bloody secretionswere cleared from the patient’s lung. Followup CXR showed drastic improvement (figure2). Over the next few days, the ventilator set-tings were weaned and the patient was extu-bated on POD #9. CXR the following day,

52 I. Condon, P. Papadakos

Figure 1: POD #5 Figure 2: POD #5 post bronchoscopy

Figure 3: POD #10 one day post extubation Figure 4: POD #10 after elective reintubationand bronchoscopy

however, showed collapse of the lung (figure3). He was intubated electively and brocn-hoscopy performed to remove the obstruc-tion. Bronchoscopic findings however wereminimal despite his poor radiographic picture(figure 4). The dilemma at this point of thepatient’s care was how to keep his left lunginflated. The patient tolerated extubation butwould quickly collapse his left lung. Keepinghim intubated for serial bronchoscopiesseemed less than ideal. On POD # 12 theICU team started the patient on intermittentpositive pressure ventilation (nPPV) at 10cmof H20 and 5cm of H20 of PEEP for 2 hours,4 times daily in addition to Dornase and ag-gressive pulmonary toilet. This therapy wascontinued for one week. Subsequent chestfilms (figures 4 and 5) showed adequate ex-pansion of the left lung and the patient didnot require any more intubations for bron-choscopies. PF progressed to toleratingroom air throughout the day with CPAP atnight for comfort.

Discussion

Non invasive respiratory support (NRS) hasbeen shown to be an effective means of pro-viding ventilatory support to certain groupsof patients in acute respiratory failure. This ismost often provided through either non inva-

sive positive airway pressure (nCPAP) or noninvasive positive pressure ventilation (nPPV).The goals of NRS are to 1) reduce the workof breathing 2) reduce atelectasis and im-prove gas exchange and 3) reduce left ven-tricular afterload. Previous studies have ex-amined the use of NRS as either a preventa-tive measure or a curative treatment.

Thoracic and abdominal surgeries nega-tively impact pulmonary function. Anesthet-ics decrease muscle tone and increase lungretractile forces and surgery itself affects di-aphragmatic function and induces pain.Arozullah et al (2) developed a risk index forpredicting post-operative pulmonary compli-cations. Depending on the number of riskfactors present, patients have a 0.5% to 31%risk of respiratory failure. Studies have shownNRS to be useful after abdominal surgery toreduce atelectasis formation (3, 4). A regi-men of nCPAP was shown to improve arterialoxygenation, reduce pulmonary complica-tions, and reduce the ICU readmission rate inpost cardiac surgery patients as well (5). An-tonelli et al. (6) showed that in organ trans-plant recipients, NRS reduced to rate of intu-bation and the incidence of ICU mortality. Ameta-analysis of patients with COPD in acuterespiratory failure showed that nPPV is effec-tive at reducing morbidity and mortality (7).

PF had a number of injuries that con-tributed to his respiratory failure. He had bi-

53Non invasive respiratory support in a multi-trauma setting

Figure 5: POD #13 after one day of nPPV Figure 6: POD #15 3 days after nPPV initiation

lateral pneumothoraces treated with chesttubes, a flail chest from numerous rib frac-tures, and a diaphragmatic injury that was sur-gically repaired. Once extubated, the patientwould quickly form atelectasis leading toopacification of his left lung field. nPPV withPEEP was effectively used to reduce his workof breathing and maintain patency of his air-way until his injuries had begun to heal. Pre-vious studies have looked at specific groupsof patients that may benefit from NRS. Thepatient in this case report presented with in-juries that were well compensated for withNRS. Its application was based on the pa-tient’s altered lung physiology. Chidini et al.(8) presents criteria for NRS application, con-traindications to its use, and how to initiatethe therapy. NRS has been shown to reducemorbidity and mortality in various situations.Physicians should consider its application inacute respiratory failure before more invasivemeasures are warranted.

References1. Kolief MH. The Prevention of ventilator-asso-

ciated pneumonia. The New England Journalof Medicine 1999; 340: 627-634

2. Arozullah AM, Daley J, Henderson WG,Khuri SF. Multifactorial risk index for predict-ing postoperative respiratory failure in menafter major noncardiac surgery. The NationalVeterans Administration Surgical Quality Im-provement Program. Ann Surg 2000; 232:242-253

3. Stock MC, Downs JB, Gauer PK, Alster JM,Imrey PB. Prevention of postoperative pul-monary complications with CPAP, incentive

spirometry, and conservative therapy. Chest1985; 87: 151-157

4. Linder KH, Lotz P, Ahnefeld FW. Continuouspositive airway pressure effect on functionalresidual capacity, vital capacity and its subdi-visions. Chest 1987; 92: 66-70

5. Zarbock A, Mueller E, Netzer S, Gabriel A,Feindt P, Kindgen-Milles D. Prophylactic nasalcontinuous positive airway pressure followingcardiac surgery protects from postoperativepulmonary complications. A prospective, ran-domized, controlled trial in 500 patients.Chest 2009; 135: 1252-1259

6. Antonelli M, Conti G, Bufi M, Costa M, Lap-pa A, Rocco M, Gasparetto A, Meduri G.Noninvasive ventilation for treatment ofacute respiratory failure in patients undergo-ing solid organ transplantion. A randomizedtrial. JAMA 2000; 283: 235-241

7. Lightowler JV, Wedzicha JA, Elliott MW, RamFS. Non-invasive positive pressure ventilationto treat respiratory failure resulting from exac-erbations of chronic obstructive pulmonarydisease: Cochrane systematic review andmeta-analysis. BMJ 2003; 326: 185-191

8. Chidini G, Calderini E, Pelosi P. Noninvasiverespiratory support (NRS) in acute respiratoryfailure. Canadian Journal of Respiratory Ther-apy 2010; 46 (2): 16-25

Correspondence address:

Peter J. Papadakos, M.D. FCCM FCCPDirector CCM The University of Rochester Medical Center 601 Elmwood AveRochester NY 14642USAPeter_Papadakos@urmc.rochester.edu

54 I. Condon, P. Papadakos